Provider Demographics
NPI:1992548242
Name:SHANNON, JAMES JR
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SHANNON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8312 REDWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-3322
Mailing Address - Country:US
Mailing Address - Phone:310-210-3013
Mailing Address - Fax:
Practice Address - Street 1:8312 REDWOOD BLVD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA CITY
Practice Address - State:CA
Practice Address - Zip Code:93505-3322
Practice Address - Country:US
Practice Address - Phone:310-210-3013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16707171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty